Abdominal myomectomy was first introduced by Boney in 1931, and it had been the only surgical procedure for years until endoscopic techniques were described. Abdominal myomectomy is still proper procedure for multiple and giant myomas. Semm described laparoscopic myomectomy in 1979 for subserosal myomas. In the beginning of the 1990s, laparoscopic myomectomy began to be performed in intramural myomas. Laparoscopic myomectomy has less hemorrhage, fewer adhesions and shorter recovery time when compared with laparotomic myomectomy. In a retrospective study with 1001 patients, Paul P.G and colleagues showed that hemorrhage and blood transfusion are the most seen complications in laparoscopic myomectomy. In a prospective study including 2050 laparoscopic myomectomy between the years 1998-2004, the overall complication rate was found 11.1%. Most seen complication was hemorrhage and mean hemoglobin drop was 1.5 g/dl. In a study about predictors of hemorrhage in laparoscopic myomectomy, there was found that hemorrhage risk is associated with duration of surgery, the largest diameter of fibroid, cumulative fibroid weight, and the number of the suture. There are numerous studies about the prediction of hemorrhage risk in laparoscopic myomectomy but none of them mention whether the location of fibroid is associated with the risk of hemorrhage or other complications. Based on these concerns, in our study we planned to detect whether hemorrhage and complication rates vary according to the location of the dominant fibroid. In our study, median fibroid size was 6.7 cm; similar with Sizzi’s large case serial (6.4cm). Our median hemoglobin drop was 1.5 g/dl in fundal group, 1.3 g/dl in anterior group and 1.3 g/dl in posterior fibroid group. The results were similar with other studies. Except of four patients (laparo-conversion), all the myomas enucleated by laparoscopy, all the patients had no severe bleeding. There was no bowel or urinary tract injury.
There are two factors associated with hemoglobin drop in LM. These are appropriate dissection cleavage during myomectomy and fast suturation after myomectomy. If the surgeon could not find the fibroid capsule properly, there would be more hemorrhage during dissection. Finding the proper cleavage may be difficult in some degenerated fibroids. The second process of the operation is suturing the myomectomy incision. Suturation may be difficult depending on the location and size of fibroid. Also, if the surgeon is not advanced, suturation time may be longer and it may cause more hemorrhage during the operation. If the surgeon is not advanced, there may be need ancillary port to make the operation with less hemorrhage. In our study we could not find the number of operations made with ancillary port.
The primary aim of the study was to obtain whether the fibroid location affects the hemorrhage rates. As the result, bleeding does not seem to vary depending on fibroid location. Although we were not able to conduct a reliable statistical comparison of complication rates due to small sample size, the observed values suggest that intramural fibroids located in the anterior wall can be more prone to have more hemorrhage than fundal or posterior wall fibroids.
There are some limitations of our study. First, all the operations were performed by 6 surgeons. Although all of the surgeons are seniors on their departments, it’s better to perform by one advanced surgeon for more reliable results. Another conflicting factor is the type of the suture material. It’s widely known that using barbed suture during myomectomy makes the duration of operation shorter with less hemorrhage and it’s shown that using barbed suture has no negative impact on myomectomy scar healing in a multicenter study. In our study, we used both types of the suture and we couldn’t analyze the effect of the suture type on LM complications.
The other concerning issue is morcellation. The major risk in morcellation is malignancy potential of fibroids. As known, occult sarcoma or leiomyosarcoma incidence during myomectomy or hysterectomy is 0.39 %. Spillage or contamination of tissues during morcellation carriages risk of dissemination of tumoral cells through abdomen and other organs and shortens the survey of survival and increases the recurrence risk. There are numerous case reports about disseminated leiomyosarcoma and sarcoma after uncontained power morcellation during myomectomy and it’s showed that uncontained power morcellation is associated with high risk of mortality in women with occult sarcoma. There are novel containing methods during myomectomy or hysterectomy; like morcellation in plastic bags.  Although there are these novel containing methods, there is still suspicion of malignancy spillage during morcellation. In our study, we morcellated all the fibroids, and plastic bag was used depending on surgeon’s choice. plastic bag was used in approximately thirty percent of the cases. There was just 1 patient in 219 with the unexpected pathology result with stump (Smooth tumors with uncertain malignant potential). There was no recurrence during six years follow up of this patient. Patient selection, age, ultrasound findings are important factors for excluding malignancy, but occult sarcoma or leiomyosarcoma may be present even without any finding. Thus, laparoscopic myomectomy should be performed under contained morcellation according to the novel studies. But recently surgeons leave laparoscopic myomectomy because of these unclear issues, and laparotomy rates begin to increase. After FDA report against the use of Power morcellation, Multinu et. Al showed that laparotomy rates in hysterectomy / myomectomy operations significantly increased and minor complication rates increased 20%. They advised balancing against the potential harms of morcellation during a shared decision-making process between clinician and patient.